The majority of diseases affecting the upper and lower jaws
of children are benign.1 Consequently, the surgical resection
of such diseases requires only narrow margins and, in turn,
commonly necessitates minimal reconstruction. In some
cases, however, larger resections resulting in a significant
deformity may be necessary to obtain appropriate diseasefree tissue margins. In cases that result in a significant bony
defect, the options for reconstructing the jaw include nonvascularized bone grafts and vascularized composite flaps.
For select defects, nonvascularized bone grafts may provide
a simple method of bony reconstruction, assuming the surrounding tissue bed is well vascularized and the patient has
a good nutritional status. Occasionally, however, the patient
has been previously exposed to chemotherapy or radiation,
or has sustained a significant bony defect, requiring a vascularized bone flap.
A variety of childhood diseases may affect the mandible or
maxilla; however, sarcomas are the most common form of
malignancy.2 Although surgical resection plays an important
role in the treatment of this disease, most often these patients
have been previously treated with chemotherapy, radiation,
or combination therapy. As a result, the recipient bed is often
compromised with regard to healing,3,4 thus limiting the
application of adjacent tissue transfer or nonvascularized
bone grafts. Although strategies to minimize the effect of
chemotherapy and radiation on the healing of soft tissue and
growth of the craniofacial skeleton have been investigated,3
under these circumstances free vascularized tissue remains
the most reliable source of bone and soft tissue.
When a surgical resection of the pediatric patient is indicated, prompt reconstruction is essential to both long-term
psychological well-being5,6 and normal craniofacial development.3,4 Over the last decade, there has been a trend to
embark on early surgical reconstruction of children with
craniofacial disorders, which has resulted in a series of
reports investigating the role of surgical reconstruction on
psychological development.5,7 Many of these studies were
prompted by a common anecdotal experience among reconstructive surgeons that children who underwent early

reconstruction of craniofacial deformities seemed to socialize postoperatively with their peers and their parents in a
more positive way than did their unreconstructed counterparts. Early studies by Pertschuk and Whitaker8 supported
these experiences, demonstrating an increase in self-esteem
and peer acceptance following surgery. Examination of the
long-term effects of facial disfigurement on social development has demonstrated convincing evidence that attractiveness plays a definitive role in normal socialization patterns,
and that children with unreconstructed craniofacial deformities are more prone to an inhibited personality style, low
self-esteem, and impaired peer relationships.9 It has been
postulated that these children harbor a poor self-image at an
early age, resulting in the development of antisocial behavior
in adolescence.9 Similarly, it has been suggested that adults
have lower expectations of disfigured school-age children,
leading to underachievement, social withdrawal, and occasionally depression.10 When early surgical intervention
occurs, however, these children tend to psychosocially adjust
in a rather short period of time. Commonly, both peer and
family interactions occur more naturally as these children
resolve their avoidance disorders.5,6,8
In addition to a healthy psychological development, a
normal physical development is important in the lives of
these patients. Although mandibular and maxillary reconstruction in children is uncommon, when faced with this
challenge it is essential that special consideration be given
to issues related to the growing child, so that the goal is to
achieve optimal restoration of mastication, deglutition, and
cosmesis. Similar to reconstruction of the adult mandible,
bone stock, soft tissue, and skin paddle design are important
factors in addressing the specific reconstructive requirements of the patient. In contrast to the adult patient, however,
the pediatric patient is growing. Because of this characteristic unique to this population, surgical reconstruction of
the upper and lower jaws requires an understanding of the
changes in bone and soft tissue architecture at both the
donor site and the mandibulofacial complex as a result of
growth and development. The commonly used donor sites,

151

Genden_5763_Chapter9_main.indd 151

2/24/2012 6:44:39 PM

M

Reconstruction of the Head and Neck
including fibula, iliac, and scapula, all possess growth centers,
areas of the bone that monitor and regulate growth and
development. Disruption of the growth center as a result of
bone flap harvest can lead to abnormal development and
long-term functional consequences. Understanding the anatomic location of these growth centers and their role in
normal development is essential to preventing long-term
functional deficits.
Similarly, the process of craniofacial development is a
dynamic one in which mandibular, maxillary, and basicranial growth are intimately interrelated. The disruption of
these relationships, as occurs with a mandibular or maxillary ablation, can result in abnormal development of the
midface, mandible, and skull base, leading to profound orodental consequences. Restoration of these relationships with
free flap reconstruction, however, can reestablish mandibulomaxillary occlusion and condylar-basicranial articulation,
leading to normal craniofacial development and oromandibular function.
In the adult patient, the selection of a donor site is based
on factors such as the requirements of the defect and the
patient’s comorbidities.11 The pediatric patient, however, is
usually healthy and in good nutritional status. Although
issues related to tissue requirements for restoration of the
defect are important in choosing a donor site, there is an
additional parameter that is of critical importance: the longterm development at the reconstructed site as well as the
donor site.

◆ NORMAL DEVELOPMENT OF
THE UPPER AND LOWER JAWS

M

Normal craniofacial development, including growth of the
mandible and maxilla, results from a series of complex
mechanisms that have been the focus of intense debate
among investigators and clinicians. Facial growth is a dynamic
process that Enlow12 refers to as the “ongoing equilibrium”
that exists among the skull base, muscle stress, and occlusal
relationships. After birth, the pediatric craniofacial skeleton
grows through two distinct mechanisms: epiphyseal proliferation and bone remodeling. Epiphyseal proliferation is
largely responsible for increases in bone length and projection (Fig. 9.1), a process that is dominant during the first 18
years of life. After age 18 the epiphyseal plate of the mandible, which is located in the proximal zone of the conical
subcondylar ridge, fuses. Consequently, the majority of the
longitudinal growth in this region is complete. Prior to
fusion, however, the epiphysis exists as a three-dimensional
structure responding to the influence of the surrounding soft
tissues, traction forces of the muscles of mastication, and the
condylar relationship with the cranial base. During the
course of facial skeletal development, the mandibular epiphysis adapts the intercondylar distance to the widening
cartilaginous synchondrosis of the cranial base, highlighting
the ever-important relationship between normal mandibular growth and normal basicranial development. A disruption of the epiphysis, the muscles of mastication, or
the temporomandibular joint prior to the fusion of the
epiphyseal plate, can result in abnormal mandibular

Fig. 9.1 The projection and growth of the mandible is a result of
epiphyseal growth demonstrated by the growth and extension of
the condylar neck.

projection and malocclusion.13 The role of epiphyseal growth,
particularly in the prepubescent pediatric patient, cannot be
overemphasized; however, a second mechanism of bone
growth called remodeling, plays an equally important part
in mandibular contour and symmetry.
In contrast to epiphyseal growth, remodeling is a process
that occurs both during the prepubescent period and
throughout adulthood. Adjustments in the downward and
forward projection of the mandible occur through deposition of bone at the posterior margin of the ramus along with
corresponding resorption at the anterior margin.12 Likewise,
mandibular contour and increased width occur as a function
of buccal bone deposition and concomitant lingual resorption. The two simultaneous processes of epiphyseal growth
and bone remodeling occur in different areas within the
same bone simultaneously, and there is no histologic difference in new bone created by either process. Although epiphyseal fusion occurs in early adolescence as part of a
genetically preprogrammed process, remodeling continues
throughout adult life largely in response to the mechanical
stress applied by the muscles of mastication (Fig. 9.2).14–16

Fig. 9.2 Mandibular and maxillary growth occur throughout
development. The growth is stimulated by muscular and mastication
stress. If there is a breakdown in this stimulation, growth will be
disrupted.

152

Genden_5763_Chapter9_main.indd 152

2/24/2012 6:44:39 PM

9 Pediatric Head and Neck Reconstruction
Understanding these principles is important in surgical
reconstruction because disruption of the mandible prior to
epiphyseal fusion may result in a different long-term developmental abnormality from a similar surgical disruption
after epiphyseal fusion. Furthermore, it is important to recognize that girls reach mature mandibular height and depth
at a mean age of 13, on average, which is 2 to 5 years earlier
than do boys.
The maxilla serves as the infrastructure of the midface;
however, it also plays an important role during facial development by providing an occlusal surface for the mandible.
This occlusal relationship functions as a feedback loop that
helps to guide both midface and mandibular development.
The ultimate form of the midface is a result of two separate
but related processes. The first is referred to as primary displacement, or growth of the maxilla bone itself, and the
second is secondary displacement, or movement of the
maxilla as a result of growth of the surrounding articulating
skeleton.12 Primary displacement results from the genetic
propensity for the maxillary bone to enlarge as a child ages,
therefore contributing to vertical maxillary growth. During
this process, periosteal resorption occurs on the nasal side
of the palate, whereas periosteal deposition occurs on the
oral side of the palate. This leads to a downward projection
of the maxilla and an enlargement of the nasal chambers.
Normal maxillary width occurs as a result of bony accretion
at the suture lines and resorption at the lateral nasal wall.
Secondary displacement is characterized by growth of the
surrounding craniofacial skeleton, namely the skull base and
the mandible, which serve to further displace the maxillary
complex downward and forward. Normal dental occlusion
acts to guide maxillary projection and preserve both the
cosmetic and functional harmony of the midface. Although
primary and secondary displacement are essential to
normal maxillary growth, a third mechanism is equally
important in the development process. The traction forces
associated with the muscles of mastication and the axial
loading forces associated with mastication also contribute
to the development process. A disruption in any or all of
these growth mechanisms prior to skeletal maturation inevitably leads to a morphologic change in maxilla. Vertical
maxillary growth is normally complete by age 14 in girls
and age 16 in boys, and fusion between the palatine processes and the maturation of maxillary width occurs at 18
years of age.
Much of what is known about facial development after
ablative surgery is derived from experimental animal
models.17 It is clear, however, that disruption of the developing maxilla or the maxillary suture lines prior to fusion
will significantly affect midface development. When disruption of the pediatric midface hinders normal occlusal
contacts, there may be a profound effect on both mandibular and maxillary development. Occlusal contact provides
bone stress, a key component to the induction of bone
growth; therefore, the occlusal interaction between the
maxilla and the mandible is paramount to ensure
normal craniofacial development. It is for this reason
that unreconstructed defects of the pediatric maxilla can
lead to significant disturbances in facial growth and aesthetic form.

DONOR-SITE SELECTION
The Fibular Donor Site
Although the developmental implications of performing a
surgical ablation on a pediatric patient may be profound, if
careful consideration is not given to the reconstruction, the
morbidity associated with a donor-site harvest may be
equally disturbing. Three donor sites have been applied to
pediatric mandibular and maxillary reconstruction: the
fibula, the scapula, and the iliac crest.18,19 Fibular growth,
which has been studied quite extensively, occurs in a classic
endochondral pattern as the three ossification centers (one
in the shaft, and one in each of the distal and proximal epiphyses) are responsible for proportionate growth (Fig. 9.3).
The growth plates lie within 1 to 2 cm of each end of the
bone, proximal and distal to where a harvesting osteotomy
is commonly made. The majority of growth occurs in the

Fig. 9.3â&#x20AC;&#x201A; The fibular growth plates lie within 1 to 2 cm of each end
of the bone, proximal and distal to where a harvesting osteotomy
should be made.

153

Genden_5763_Chapter9_main.indd 153

2/24/2012 6:44:39 PM

M

Reconstruction of the Head and Neck
proximal epiphyseal plate that fuses by age 15 in girls and
age 17 in boys.20 Similar to that in the adult, the fibula offers
the longest segment of bone of the three donor sites;
however, the stock of bone, particularly in patients under the
age of 13, may lack the height appropriate to stabilize
osseointegrated implants. In such cases, the fibula can be
“double barreled”21 by creating a midpoint osteotomy and

M

folding the bone upon itself. This results in an increase in the
bone height and a more stable foundation for osseointegrated implants (Fig. 9.4). The double-barreled fibula can be
secured upon itself by placing a vertical lag screw or circumosseous wires at each end of the complex.
Essential to achieving a successful long-term reconstruction, transferred bone must grow at a rate similar to that of

Fig. 9.4 The stock of bone of the fibula, particularly in patients under the age of 13, may lack the height appropriate to stabilize
osseointegrated implants. The bone graft can be “double barreled” to increase bone stock height. This is helpful for the eventual placement of
osseointegrated implants.

154

Genden_5763_Chapter9_main.indd 154

2/24/2012 6:44:40 PM

9 Pediatric Head and Neck Reconstruction
the native mandible or maxilla. Concern regarding growth of
the transferred bone, particularly in a developing child, has
led investigators to find the ideal transplantable epiphysis.
Epiphyseal transfer in the iliac and fibula has proven successful in the treatment of epiphysiodesis and acetabular defects
in children; however, the necessity to transfer an epiphyseal
growth plate in jaw reconstruction has not been clearly
demonstrated.22–24 Epiphyseal plates are not routinely transferred during the harvest of the fibula; however, the fibula
will continue to grow at a rate comparable with that of the
adjacent native mandible (Fig. 9.5).25–28 It is likely that this
occurs because a growth center remains within the shaft of
the transferred bone. It has been shown experimentally,
however, that when an epiphyseal plate is transferred in a
vascularized bone segment, it retains the potential for
growth.26,29 Although it has not been reported clinically, this
may serve as a potential source for condylar reconstruction
in the prepubescent pediatric patient.
Harvesting the fibula from a growing limb has raised concerns among reconstructive surgeons; however, there is
little clinical evidence that suggests long-term limb growth
is adversely affected.18,30 Although experimental evidence in
rats suggests that the fibula exerts a restrictive effect on
tibial growth such that removal of the fibula leads to longitudinal tibial overgrowth,28 we have not observed this clinical phenomenon in our series.18 The most significant delayed
complication associated with fibular harvest, particularly in
children under the age of 8, is the development of a valgus
deformity.30,31 An ankle valgus may result from a variety of
etiologies including multiple hereditary exostoses, poliomyelitis, congenital pseudarthrosis of the fibula, and fibular
harvest. When it does occur, it can lead to chronic pain syndromes and a profound gait disturbance. Several strategies

Fig. 9.6 Ossification of the scapula proceeds in a superior to inferior
pattern until approximately age 10, when the scapula is roughly 12
cm long and the distal epiphysis has decreased to only 4 cm. A
smaller but equally important growth plate exists superiorly,
adjacent to the glenoid fossa.

have been proposed for both the prevention and the management of this deformity, including partial epiphysiodesis
with staples, tibiofibular (TF) synostosis, and transphyseal
fibula-tibial screw.31 Omokawa et al30 reviewed 13 cases of
pediatric fibular harvest in which patients were divided into
two groups: one received a TF synostosis and the other did
not undergo a synostosis. The postoperative observation
period ranged from 5.8 years to 16.5 years. In the former
group, a valgus deformity was observed in only one patient,
whereas in the latter group all of the children under the age
of 8 years developed a valgus deformity. Irrespective of the
method of tibiofibular stabilization, it is clear that in children
under 8 years of age who did not undergo a synostosis, the
prevention of a valgus deformity is essential following fibular
harvest.

The Scapular Donor Site

Fig. 9.5 Clinical case. Two years following a fibular reconstruction of
the hemi-mandible, growth and symmetry are stable.

Unlike the fibula, the scapula is a flat membranous bone;
however, the lateral scapular border is analogous to a long
bone whose distal end is formed by a large osteocartilage
epiphyseal plate. At birth, the distal 7 to 8 cm of the scapula
are composed entirely of hyaline cartilage, and it is this osteocartilage apophysis that is responsible for the development
of four fifths of the scapula.32 Ossification proceeds in a superior to inferior pattern until approximately age 10, when the
scapula is roughly 12 cm long and the distal epiphysis has
decreased to only 4 cm (Fig. 9.6). A smaller, but equally
important growth plate exists superiorly, adjacent to the
glenoid fossa.32 Mainly responsible for vertical scapular
growth, the superior growth plate lies outside the range
of harvested bone, and therefore should not be directly
affected. Both superior and inferior growth plates fuse at

155

Genden_5763_Chapter9_main.indd 155

2/24/2012 6:44:41 PM

M

Reconstruction of the Head and Neck
approximately age 20, so that normal scapular development
is disrupted after harvesting bone from the distal scapula in
the pediatric patient. Similarly, the lateral border of the
scapula serves as a traction epiphysis, growing in response
to traction by the teres and triceps muscle groups.29 A disruption in the muscular attachments or a disruption in the
lateral scapular border, may lead to an arrest in scapular
development. Concerns regarding the long-term consequences of a bone harvest in this region have been addressed
by Teot et al,32 who examined a series of three patients who
had undergone scapular free flap reconstruction of congenital limb amputation. They found that harvesting bone from
the lateral border and distal scapula resulted in a moderate
scapular size discrepancy. They compared plain radiographs
of the operated scapula with the nonoperated scapula 5
years postoperatively, and found that although there was a
3-cm discrepancy in scapular length as a result of arrested
growth, there was no appreciable limitation to range of
motion or strength when compared with the contralateral
scapula. They concluded that the upper growth plate must
compensate for disruption of the scapular epiphysis, although
there is no objective data to support this claim. Similarly, in
our series we have found that pediatric patients recover
completely following harvest from the scapular donor site.
With the aid of physical therapy, full range of motion and
strength are recovered within 6 weeks.18
The scapular donor site has been used quite extensively
for pediatric limb reconstruction; however, it has not been
commonly used for pediatric jaw reconstruction. Although
the presence of an active epiphysis as part of the bone graft
has a theoretic advantage for reconstructing a growing
patient, this issue has not been carefully studied. Because it
has been shown that transferred epiphyseal bone will continue to grow at a rate that is linearly related to the amount
of stress applied to that bone,16 it is important to achieve
orodental rehabilitation as soon as possible. Although the
lateral border and distal tip of scapula provide bone adequate for the retention of osseointegrated implants in
adults,33 the pediatric scapula may be quite thin and limit
implant stability. In this situation, nonvascularized onlay
bone grafts placed either primarily or secondarily may be
used to augment the scapular bone to facilitate implant stability. The placement of implants followed by implant-borne
dentures will in turn provide the bone stress necessary to
stimulate continued bone growth.

The Iliac Donor Site

M

The entire length of the iliac crest, from the anterior-superior
to the posterior-superior iliac spines, is composed of cartilage at birth. Growth occurs in an epiphyseal fashion in
several areas of the pelvic girdle, including the acetabulum
and the iliac crest, which grow until the second decade of
life (Fig. 9.7). The mechanical demands applied to the pelvis
by both its upper and lower muscular attachments play an
integral role in pelvic remodeling, which occurs into young
adulthood. A disruption in the epiphysis prior to its fusion
may have a profound effect on the development of the pelvic
girdle. Rossillon et al34 reviewed 21 children over an average

Fig. 9.7â&#x20AC;&#x201A; Growth of the iliac occurs in an epiphyseal fashion in
several areas of the pelvic girdle including the acetabulum and the
iliac crest, which grow until the second decade of life.

of 3 years and 10 months who had undergone a surgical
disturbance of the iliac epiphysis. They demonstrated that
16 of these children developed iliac hypoplasia as a result of
premature arrest in growth; however, no functional evaluation was performed on the children in this series.
Like the lateral scapular border, the iliac crest serves as a
traction epiphysis where the dynamic interaction between
the iliac crest and its muscle attachments play a crucial role
in acetabular development and hence gait stability. Lee
et al35 examined the effect of an injury of the iliac apophysis
on the subsequent growth of the pelvis. They examined
immature New Zealand rabbits and found that excision of
any more than one third of the iliac apophysis resulted in
retarded growth of the iliac bone. A similar study by Olney
et al36 found that a lesser injury, such as a splitting of the iliac
apophysis, was enough to adversely affect normal iliac development. In the adult population, disturbance of gait after
iliac crest free flap harvest has been documented in up to
11% of patients37,38; however, there is little published on the
long-term effects of iliac crest harvest in the pediatric population. Boyd19 reviewed five patients between the ages of 16
and 27 years who had undergone mandibular reconstruction
using a free vascularized iliac crest free flap. He found
minimal donor-site morbidity in his series of young adults;
however, the youngest patient in his series was 16 years old.
Although this donor site has been suggested as ideal for
pediatric mandibular reconstruction,39 the probability of
postoperative gait disturbance in a younger age group has
discouraged most surgeons from utilizing this donor site. As
a result, there are no reported series of iliac crest free flap
reconstructions in the prepubescent pediatric population.

156

Genden_5763_Chapter9_main.indd 156

2/24/2012 6:44:41 PM

9 Pediatric Head and Neck Reconstruction

◆ GROWTH OF VASCULARIZED
BONE GRAFTS
Although fibular and scapular flaps have been used quite
extensively by plastic surgeons for the reconstruction of
acquired and congenital limb abnormalities, there is little
reported on the long-term growth of the transferred bone
after mandibular and maxillary reconstruction. Although
one may consider that the information gleaned from pediatric extremity reconstruction can be applied to bone growth
in the reconstructed jaw, it is not clear that these principles
can be universally applied. There is good evidence that osteocyte viability is preserved after the transfer of non–
epiphyseal-containing vascularized bone grafts25–28; however,
the bone growth may be unpredictable. Experimental evidence suggests that vascularized membranous bone grafts
utilized in the reconstruction of mandibular and zygomaticomaxillary defects in immature animals contribute to
normal craniofacial development in a more predictable
fashion than nonvascularized bone grafts,40 but there is little
evidence to support this clinically. It has been speculated
that the growth of transferred bone grafts is influenced by
the adjacent craniofacial skeleton. We have seen symmetrical maxillary and mandibular growth in pediatric patients
reconstructed with both scapular and fibular free flaps;
however, the influence of the native craniofacial bone on
bone graft growth is a difficult relationship to establish.
Clearly, the proven linear relationship between bone stress
and bone growth16 may be responsible for symmetrical
growth of the transplanted bone, making this issue particularly complicated.

◆ CONCLUSION
Pediatric reconstruction is relatively rare. Although most of
the concepts for adult reconstruction hold true for the pediatric patient, the potential for donor-site morbidity is unique
in the pediatric population. The knowledge of growth plate
and ossification centers is important in limiting donor-site
morbidity.